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ForwardPCMH 2025 Post Hospital Follow-Up Sprint - Session #3 - JHF
Participants will engage in peer-to-peer learning around implementation of key interventions, including successful tactics and challenges and barriers. Participants will also learn about role of risk stratification in effective post-hospitalization follow-up for primary care practices and discuss tactics for implementation.
Agenda:
9:00 a.m. to 9:30 a.m. – Welcome, Survey Feedback & Presentation on high level framing of the impact of risk-stratified hospital follow up and evidence for what works – Suzanne Cohen, MPH, Senior Director of Population Health, Health Federation of Philadelphia
- Share evidence-base for risk stratified hospital follow-up
- Present survey data results
9:30 a.m. to 10:15 a.m. – PCMH report outs on risk stratification approach
- What (if any) risk stratification algorithm is your PCMH using?
- How are you getting access to the data needed for accurate risk stratification.
- How is the risk level presented to your teams?
- How are you using risk stratification? i.e. who gets prioritized? Is there a cutoff for who gets follow-up? Are different team members/timeframes assigned based on risk?
- Are you able to measure results/impact on readmissions or other outcome measures based on risk?
- What questions do you have for us about risk stratification in effective post-hospitalization follow-up?
10:15 a.m. to 10:30 a.m. – Wrap-up, Next Steps & Evaluation – Suzanne Cohen, MPH, Senior Director of Population Health, Health Federation of Philadelphia
Target Audience
Nurse
Physician
Social Worker
Learning Objectives
- Describe the role of risk stratification in effective post hospitalization follow-up.
- Describe progress in implementing risk stratification across participating practices.
- Collaborate on finding solutions to common obstacles encountered in implementing interventions.
Additional Information
| Attachment | Size |
|---|---|
 Audience Disclosure slides (001.5)_14.pptx | 460.14 KB |
 Draft Agenda_August 14_PostHospital_HealthChoices PCMH Learning Network.docx | 51.71 KB |
Participants will engage in peer-to-peer learning around implementation of key interventions, including successful tactics and challenges and barriers. Participants will also learn about role of risk stratification in effective post-hospitalization follow-up for primary care practices and discuss tactics for implementation.
Agenda:
9:00 a.m. to 9:30 a.m. – Welcome, Survey Feedback & Presentation on high level framing of the impact of risk-stratified hospital follow up and evidence for what works – Suzanne Cohen, MPH, Senior Director of Population Health, Health Federation of Philadelphia
- Share evidence-base for risk stratified hospital follow-up
- Present survey data results
9:30 a.m. to 10:15 a.m. – PCMH report outs on risk stratification approach
- What (if any) risk stratification algorithm is your PCMH using?
- How are you getting access to the data needed for accurate risk stratification.
- How is the risk level presented to your teams?
- How are you using risk stratification? i.e. who gets prioritized? Is there a cutoff for who gets follow-up? Are different team members/timeframes assigned based on risk?
- Are you able to measure results/impact on readmissions or other outcome measures based on risk?
- What questions do you have for us about risk stratification in effective post-hospitalization follow-up?
10:15 a.m. to 10:30 a.m. – Wrap-up, Next Steps & Evaluation – Suzanne Cohen, MPH, Senior Director of Population Health, Health Federation of Philadelphia
Suzanne Cohen, MPH, Senior Director of Population Health, Health Federation of Philadelphia
In support of improving patient care, this activity has been planned and implemented by the University of Pittsburgh and The Jewish Healthcare Foundation. The University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
As a Jointly Accredited Organization, University of Pittsburgh is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. University of Pittsburgh maintains responsibility for this course. Social workers completing this course receive 1.5 continuing education credits.
Physician (CME)
The University of Pittsburgh designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Nursing (CNE)
The maximum number of hours awarded for this Continuing Nursing Education activity is 1.5 contact hours.
Social Work (ASWB)
The maximum number of hours awarded for this Continuing Social Work Education activity is 1.5 contact hours.
Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.
Available Credit
- 1.50 AMA PRA Category 1 Credit™The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
- 1.50 ANCCUPMC Provider Unit is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation
- 1.50 ASWB
- 1.50 Attendance